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Transcript of Digoxin Toxicity
Dysrhythmias (brady- or tachy-)
Delayed after depolarization
Possible mechanism for digoxin-induced tachycardia 3 non cardiac manifestations from class?
Electrolyte imbalance EKG Acute Toxicity Decreased AV nodal conduction
EKG? Only 25% of digoxin plasma is bound to protein and it is mainly excreted through kidneys
Hemodialysis is not effective in digoxin overdose
Hemoperfusion -lack of evidence
Management 1) Immediate lavage performed
Activated charcoal (1g/kg) administered through nasogastric tube
2) Magnesium Sulfate 1 gram IV
3) Transcutaneous pacing
4) Temporary pacemaker inserted Management 3 Treatment Hemoperfusion with resin-based cartridge done over 4 hours Digifab – therapy we learned in class
Why wasn’t Digifab used? Monitor: Platelets, coagulation profile, serum electrolytes, and digoxin levels monitored regularly
What electrolyte should we be most concerned about?
K+– (0.5-1 = normal) over 2 = toxic Dolla Dolla Bills y’all Assessment Treatment guidelines for digoxin toxicity
Gastric lavage within 4 hours of drug ingestion.
Activated charcoal 100 g to increase clearance
Atropine for immediate management of heart block
Resistant cases may require temporary cardiac pacing
DigiFab transfusion is used to rapidly reduce serum digoxin concentrations in patients with life-threatening arrhythmias Assessment of Therapy Alternative therapy:
Hemoperfusion with charcoal or resin filters is used to manage patients with digoxin toxicity when Fab fragments are unavailable.
Magnesium therapy as a temporizing antiarrhythmic agent until fab fragments are available. Shown to terminate digoxin-toxic cardiac arrhythmias in patients with and without overt disease. References Questions? Severe suicidal digoxin toxicity managed with resin hemoperfusion: A case report National Institutes of Health 30 year old female
Ingested 70 tablets of 0.25 mg digoxin 1 hour prior to presentation
Total dose = 17.5 mg
Nausea & recurrent vomiting 20 mins after ingestion
Allergies and medications
Information not available The Patient Conscious & oriented
BP 106/70, HR 102, RR 20, O2 Sat 99% RA, afebrile
Within 2 hours:
Diplopia, blurring, yellowing of vision
Intermittent episodes of bradycardia with hypotension (HR 30, SBP 70)
ECG: variable & prolonged PR with atrial ectopics, which subsequently converted into complete heart block Patient Presentation Serum digoxin 12.63 ng/ml
(Normal 0.5-2 ng/ml)
Na+ 137 mmol/L
K+ 4.6 mmol/L
Ca2+ 8.3 mg/dL
Mg2+ 3.13 mg/dL
CBC, Liver/Renal Function Tests: WNL LABS Treatment Outcome No complications
Gradual symptomatic improvement
Vision cleared and N/V resolved within 4 hours
AV block corrected over next 24 hours
Remained asymptomatic & discharged after 4 days of hospitalization 1. Sanoski CA, Bauman JL. Chapter 25. The Arrhythmias. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. http://0-www.accesspharmacy.com.wildpac.wne.edu/content.aspx?aID=7972803. Accessed April 30, 2013.
2. Juneja D, Singh O, Bhasin A et al. Severe suicidal digoxin toxicity managed with resin hemoperfusion: A case report. Indian J Crit Care Med. 2012;16(4):231-233 Clinical Pearls Widely used, but has a narrow therapeutic index
Non-cardiac symptoms: vomiting (acute), yellow halos (chronic)
Cardiac symptoms: intermittent episodes of bradycardia Activated charcoal
Side effects: constipation, black stools, GI tract Magnesium sulfate
Side effects (not common): breathing difficulties, HA, N &V etc. Monitor K+ and Mg2+ levels Visual disturbances
Blurred or yellowed vision
Range for serum digoxin
0.5 ng/mL – 2 ng/mL
More Abnormalities 4 3 Clinical Pearls